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Substance abuse in SA: the critical need for more usable research

Substance abuse is a growing problem in South Africa, with just more than 13% of the population having used a substance during their lifetime. But the lack of comprehensive data to understand the changing trends of substance use and the lack of treatment facilities leaves much to be desired. Ina van der Linde reports on two seminars on substance abuse facilitated by the Department of Science and Technology and hosted by the HSRC.

Research on substance abuse is fairly conclusive: South African police data shows a 123% increase in drug-related crimes from 2003/2004 to 2013; driving under the influence of alcohol increased by 148% in this period.

During this period, the national injury mortality surveillance system on post-mortem investigations found that 54% of violence-related deaths and 52% of transport-related deaths were alcohol-related. A study at five trauma units in Cape Town, Durban and Port Elizabeth found that one-third of patients tested positive for cannabis, 15% for metaxalone and 14% for white pipe (combination of cannabis and metaxalone). The same study showed violence was strongly related to the use of substances: 67% of trauma cases in these hospitals was alcohol related, 45% related to illicit drug use, 84% related to at least one substance, 40% related to cannabis use, and 17% related to white pipe use.

These are some of the statistics from two research seminars that aimed to encourage a wider dissemination and application of research in the social sciences and humanities. The seminars brought together local and international researchers to discuss the latest research, identify research gaps, suggest new research agendas and explore potential policy relevance.

Of interest was an analysis of the effects of specific drug types on behaviour, for example, amphetamines and cocaine were associated with violence; opiates with illegal opiate procurement and sex work, and cannabis with impacted concentration and reaction times.

13.3% of the South African population had used drugs during their lifetime.

South Africa’s ever-increasing drug challenge

Dr Paul Seale, Mercer University School of Medicine, USA, researched drug use in South Africa and found that 13.3% of the South African population had used drugs during their lifetime, resulting in substance abuse in 3.9% of people and dependence in 0.6% of the population. There were high levels of inhalant use among youth, he said. Cannabis (dagga) was the drug of choice among those undergoing substance abuse treatment, and methamphetamine (tik) abuse was common in the Western Cape and Eastern Cape. There was also a noticeable increase in the use of over-the-counter and prescription medicines, especially by young people, which includes the highest use of methaqualone (mandrax/Quaalude) in the world.

Of concern was the use of emerging new concoctions, such as nyaope (whoonga), which may contain dagga, heroin, household cleaner, rat poison and the HIV drug Efavirenz.

He pointed out that countries with economies in transition and developing countries have become increasingly affected by illicit drug use as they have experienced a range of socioeconomic changes. ‘In absolute numbers, there are almost twice as many illicit drug users in [these] countries…’

We should aim to collect self-report and bio-marker data in national surveys.

Seale emphasised the role environment played in drug abuse, including the level of urbanisation, socioeconomic status, ethnic diversity and genetics, the latter contributing to 50% of the risk of addiction. Quoting from the US National Institute on Drug Abuse’s mission statement, he said there is a need to change people’s perceptions, replacing stigma and shame with a new understanding of addiction as a treatable disease.

Quest for data on substance abuse

But to understand addiction, information is needed in the form of data gained from surveys to inform the prevalence of unhealthy substance use; identify areas of special need; highlight new emerging substances and their effects and consequences; and raise consciousness by educating the public and policy makers.

Professor Pamela Naidoo, research director at the HSRC, also emphasised the use of surveys for data-gathering, saying existing information was mostly restricted to sub-groups.

‘We must continue with surveys but use innovative approaches to reach adolescents who are out of school and drug users who are not in treatment. Ideally we should aim to collect self-report and bio-marker data [for example, blood tests] in national surveys to get a more accurate account of the presence and the levels of toxicity in the bloodstream at the time of data collection.’

Drug use is often under- or over-estimated, and survey participants do not always want to disclose their drug use. What is needed are national surveys every three to five years that follow drug consumption trends; disaggregate data for sex, age and geographic region, and to evaluate interventions. This information would be useful to draw up budgets for research, treatment and prevention.

Treatment for drug addition

The lack of treatment services was emphasised by Dr Katherine Sorsdahl, University of Cape Town. Several provinces having only one residential treatment facility and the Northern Cape has none.

She described several interventions, but said a shortage of finances prevented the possibility to scale up these interventions and to make them routinely available in all parts of the country. But what happens to people after they have been treated at a facility and they return to their community? This question was posed by a pastor who pleaded for after-care services, saying that often former drug-users, often severely damaged by years of substance abuse, come back into the community without any support.

Hope resides in the South African Mental Health Care Policy Framework (2013–2017) that embraces ‘task shifting’ as a strategy for more substance abuse services in primary health care settings, Sorsdahl said. Task shifting models imply using nurses or community health workers instead of medical doctors.

Table 1: Number of professionals available in the public sector

The next step

Recommendations for policy included performing an audit of substance abuse research to make existing research more widely available, and to assess the reliability and validity of results. Population-based surveys over time are still the best method to answer key research questions about the national situation and will generate reliable data on incidence, prevalence and trends.

Participants concluded that the effectiveness of treatment and rehabilitation needed to be properly evaluated; patient management and tracking remained problematic, and research was required on ‘the multi-level influences on the individual’ to better understand social support, the role of family and the community, coping strategies and resilience.

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